Who Gets a New Kidney? Healthier People Could Have Priority

By Amanda Glassman

Thousands die each year because there aren't enough kidneys to go around. A new policy could rethink who should live.

In the health sector,
policy choices can be a matter of life or death. And as spending cuts
hit federal and state programs, people are being forced to make hard
choices.

Recently, Rob Stein of The Washington Post
wrote about how the United Network for Organ Sharing, the nonprofit
that manages America's organ transplant system under contract with the
federal government, has proposed a new way to allocate kidneys for
transplantation. Its 30-member Kidney Transplantation Committee is
considering a new system that would provide kidneys to those with the
best chances for survival first, in lieu of using waiting lists.

Not
everyone who needs a kidney will receive one. Stein writes that more
than 87,000 Americans are on a waiting list for a kidney and only about
17,000 will receive a transplant. More than 4,600 will die each year
because they do not receive a kidney in time.

Using what is
often called "effectiveness analysis" to determine which recipients will
gain the most years of healthy life from a transplant is a new approach
in a country that has been loath to consider the health implications of
its health care coverage decisions. The ethical issues are not simple.
The proposed approach to kidney allocation ignores the rule of rescue,
which argues that the sickest must be treated first, even when money
might be more efficiently spent to improve health in the broader
population. It has equity implications, valuing the lives of the young
more than the old. Some are already calling the proposal age
discrimination.

More than 87,000 Americans are on a waiting list for a kidney and only about 17,000 will receive a transplant.

To address the ethical issues, the Committee issued a document
including their full proposal (as well as other alternatives that they
considered), and it has invited the public to provide comments and
feedback. It notes, "This process has taken almost six years to date and
has involved hundreds of individuals including transplant
professionals, transplant recipients, transplant candidates, donor
family members, living donors, and members of the general public."

This
is an important development in U.S. health policy. There is both
explicit consideration of the ethical issues raised by the
recommendation and a sound evaluation of comparative effectiveness: an
in-depth look at the benefits and harms of different interventions and
strategies to address real-world health conditions. It is a baby step
away from the current approach, which rations according to a person's
access to health care services, and toward a simpler, more transparent,
evidence-based decision-making process. You might not agree with the
kidney transplant recommendation. And you certainly should have the
opportunity to express and defend your position. But at least the
government is prepared to provide enough information so you can
understand why the decision was taken and appeal if necessary.

In the
U.S., we don't like talking about rationing. But as hard as these
discussions may be, they are necessary when resources are scarce and the
health system needs to produce more "health" and not just services.
Other countries often don't think about these issues the way we do.
Among developed nations, the U.K. is a front-runner in thinking about
rationing, and some other European nations are also keeping pace.

Strangely,
it is the less affluent countries that are moving faster toward
explicit priority-setting in health care. In 2010, Colombia found itself
funding an increasing number of high-cost, low-impact interventions,
such as bariatric surgery, while underfunding cost-effective public
health interventions. This year, the country created a health technology
assessment agency to carry out economic evaluations, consult and
deliberate with the public and stakeholders, and recommend interventions
and target groups to be included or excluded for public funding under
their insurance scheme.

Can the U.S. catch up? At the Center for
Global Development, we will soon convene a group of international
experts to benchmark priority-setting processes and institutions
worldwide and identify the strategies in this space that work the best.
There may well be something in there for us Americans. Stay tuned.